The longitudinal relationships between family physicians and their patients contribute to increased patient and physician satisfaction and produce system-wide benefits, including better health outcomes and lower overall cost.^1,2 Children with access to stable insurance coverage have improved health, lower rates of disability, and greater financial security into adulthood. Gaps in coverage that disrupt care impact the nation's children particularly hard, a situation exacerbated by the end of the COVID-19 public health emergency.^3,4

State Medicaid programs typically experience high turnover among enrollees due to income fluctuations, with 10% of participants disenrolling and reenrolling during a 12-month period.⁵ This turnover, often referred to as “churn,” disproportionately impacts children and younger adults compared with adults older than 65 years and those with disabilities.⁵

With millions of Americans losing employment in the early months of the COVID-19 pandemic, the Families First Coronavirus Response Act sought to reduce Medicaid churn by increasing federal support for states that agreed to maintain continuous enrollment for individuals enrolled as of March 18, 2020.⁶ This enhanced federal support and continuous enrollment requirement propelled Medicaid enrollment to a high of 94.5 million in April 2023, an increase of 23.1 million (approximately 30%) from prepandemic levels in February 2020.⁷ Medicaid enrollees include one-half of US children (approximately 40 million) covered by the Children's Health Insurance Program (CHIP), which provides low-cost coverage to children whose parents are just above the Medicaid eligibility threshold.

With the COVID-19 public health emergency behind us, federal funding tied to continuous Medicaid coverage is no longer available. The cost of continuing coverage now falls to states. Although some states are continuing coverage, especially for children, many are disenrolling millions of adults and children from their Medicaid programs. Only a small number of those individuals losing Medicaid eligibility are expected to be eligible for subsidized coverage through their state-based marketplace exchange or an employer-sponsored plan. More troubling is that as many as 70% of disenrollments occur for procedural reasons, such as individuals not receiving or responding to renewal notices, recipients not understanding the renewal requirements, or errors in submitted paperwork.⁸ A loss in coverage, regardless of the reason, results in children not receiving required immunizations, well visits, and care for otherwise common acute concerns. These needs could instead be managed in emergency settings that lack the benefits of continuous primary care.

To mitigate unnecessary loss of coverage, Congress included provisions in the 2023 Consolidated Appropriations Act to guide states through this “Medicaid unwinding.” One of these provisions includes a requirement to provide 1 year of continuous Medicaid coverage for children. Although the American Academy of Family Physicians (AAFP) offered strong support, continuous coverage requirements are limited because they apply only to children who have been renewed or newly enrolled in Medicaid or CHIP within the past 12 months. Some states provide continuous coverage to young children for several years, underscoring the variability in states' approaches to Medicaid unwinding.

We must act now to avoid an unnecessary loss of Medicaid coverage for millions of children. The AAFP has strongly supported rules proposed by the Centers for Medicare and Medicaid Services to reduce Medicaid coverage churn and urges them to implement these policy changes:

• Improve integration of CHIP and Medicaid

• Provide flexibility, support, technical assistance, and oversight to state Medicaid agencies to minimize coverage disruptions by (1) using ex parte renewals (if a beneficiary's information has not changed, they do not need to take action to continue coverage) and leveraging information from other safety net programs, such as Supplemental Nutrition Assistance Program for Women, Infants and Children, to verify eligibility; (2) ensuring availability of robust translation and culturally competent patient support resources; and (3) monitoring denials to ensure complete information is accessible and network adequacy standards are appropriately enforced

• Ensuring adequately funded primary care payment that positions family physicians to provide the care that all patients deserve through achieving payment equity between Medicaid and Medicare.

Family physicians value timely access to comprehensive continuous care—especially for vulnerable populations, such as children. The voices of family physicians who can attest to these critical aspects of children's care are important. Get involved through your AAFP state chapter or by directly reaching out to your state representatives or regulatory leaders. It will take all of us working together to advance both near-term remedies and bold policy shifts to ensure that Medicaid remains an accessible, reliable source of coverage for our nation's children.

Editor’s Note: Stephanie Quinn is senior vice president of external affairs and practice experience at the AAFP.